Search

Background & Aims: Helicobacter pylori infection is increasingly difficult to treat. The purpose of these consensus statements is to provide a review of the literature and specific, updated recommendations for eradication therapy in adults., Methods: A systematic literature search identified studies on H pylori treatment. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an online platform, finalized, and voted on by an international working group of specialists chosen by the Canadian Association of Gastroenterology., Results: Because of increasing failure of therapy, the consensus group strongly recommends that all H pylori eradication regimens now be given for 14 days. Recommended first-line strategies include concomitant nonbismuth quadruple therapy (proton pump inhibitor [PPI] + amoxicillin + metronidazole + clarithromycin [PAMC]) and traditional bismuth quadruple therapy (PPI + bismuth + metronidazole + tetracycline [PBMT]). PPI triple therapy (PPI + clarithromycin + either amoxicillin or metronidazole) is restricted to areas with known low clarithromycin resistance or high eradication success with these regimens. Recommended rescue therapies include PBMT and levofloxacin-containing therapy (PPI + amoxicillin + levofloxacin). Rifabutin regimens should be restricted to patients who have failed to respond to at least 3 prior options., Conclusions: Optimal treatment of H pylori infection requires careful attention to local antibiotic resistance and eradication patterns. The quadruple therapies PAMC or PBMT should play a more prominent role in eradication of H pylori infection, and all treatments should be given for 14 days., (Copyright © 2016 AGA Institute. Published by Elsevier Inc. All rights reserved.)

The diminishing prevalence of Helicobacter pylori infection among most segments of the Canadian population has led to changes in the etiologies and patterns of associated upper gastrointestinal diseases, including fewer peptic ulcers and their complications. Canadian Aboriginals and recent immigrants are among populations in which the prevalence of H pylori infection remains high and, therefore, the health risks imposed by H pylori remain a significant concern. Population-based strategies for H pylori eradication in groups with a low prevalence of infection are unlikely to be cost effective, but such measures are attractive in groups in which the prevalence rates of infection remain substantial. In addition to a lower prevalence of peptic ulcers and dyspepsia, the public health value of eradication may be particularly important if this leads to a reduction in the prevalence of gastric cancer in high prevalence groups. Therefore The Canadian Helicobacter Study Group held a conference that brought together experts in the field to address these issues, the results of which are reviewed in the present article. Canadians with the highest prevalence of H pylori infection are an appropriate focus for considering the health advantages of eradicating persistent infection. In Canadian communities with a high prevalence of both H pylori and gastric cancer, there remains an opportunity to test the hypothesis that H pylori infection is a treatable risk factor for malignancy.

As an update to previously published recommendations for the management of Helicobacter pylori infection, an evidence-based appraisal of 14 topics was undertaken in a consensus conference sponsored by the Canadian Helicobacter Study Group. The goal was to update guidelines based on the best available evidence using an established and uniform methodology to address and formulate recommendations for each topic. The degree of consensus for each recommendation is also presented. The clinical issues addressed and recommendations made were: population-based screening for H. pylori in asymptomatic children to prevent gastric cancer is not warranted; testing for H. pylori in children should be considered if there is a family history of gastric cancer; the goal of diagnostic interventions should be to determine the cause of presenting gastrointestinal symptoms and not the presence of H. pylori infection; recurrent abdominal pain of childhood is not an indication to test for H. pylori infection; H. pylori testing is not required in patients with newly diagnosed gastroesophageal reflux disease; H. pylori testing may be considered before the use of long-term proton pump inhibitor therapy; testing for H. pylori infection should be considered in children with refractory iron deficiency anemia when no other cause has been found; when investigation of pediatric patients with persistent or severe upper abdominal symptoms is indicated, upper endoscopy with biopsy is the investigation of choice; the 13C-urea breath test is currently the best noninvasive diagnostic test for H. pylori infection in children; there is currently insufficient evidence to recommend stool antigen tests as acceptable diagnostic tools for H. pylori infection; serological antibody tests are not recommended as diagnostic tools for H. pylori infection in children; first-line therapy for H. pylori infection in children is a twice-daily, triple-drug regimen comprised of a proton pump inhibitor plus two antibiotics (clarithromycin plus amoxicillin or metronidazole); the optimal treatment period for H. pylori infection in children is 14 days; and H. pylori culture and antibiotic sensitivity testing should be made available to monitor population antibiotic resistance and manage treatment failures.

Previous consensus statements have recommended one- to two-week proton pump inhibitor (PPI)-based triple therapies with clarithromycin and either amoxicillin or metronidazole as first-line treatments for children with Helicobacter pylori infection. The objective of the present review was to summarize data from pediatric studies that have examined treatment efficacy, safety, drug resistance and reinfection rates related to anti-H. pylori therapies. Data from a recent meta-analysis of pediatric studies were used along with the authors' existing databases and searches of individual studies. Regimens that were identified as greater than 80% efficacious in children included a two-week therapy with a nitroimidazole and amoxicillin in Europe; a two-week regimen of bismuth, amoxicillin and metronidazole in developed countries (except Spain); a one- to two-week regimen of a PPI, clarithromycin and amoxicillin in Northern Europe, Asia and the Middle East; and a two-week regimen of a PPI, clarithromycin and metronidazole in Canada. Although recommended as a first-line treatment in adults, two-week treatment with a PPI, clarithromycin and amoxicillin eradicated only 68% of H. pylori infections in North American children. Treatment efficacy was reduced in the presence of metronidazole and/or clarithromycin resistance. Further studies of anti-H. pylori treatments in children in North America and developing countries are warranted.

Objective: To assess Helicobacter pylori eradication after one week dual ranitidine bismuth citrate-clarithromycin (RBC-C) or triple omeprazole, clarithromycin and amoxicillin (OCA) therapy., Methods: In this multicentre Canadian trial, H pylori-positive patients with functional dyspepsia or inactive peptic ulcer disease were randomized to open-label treatment with RBC-C (ranitidine bismuth citrate 400 mg plus clarithromycin 500 mg) or OCA (omezaprole 20 mg, clarithromycin 500 mg and amoxicillin 1000 mg), given twice a day for seven days. Treatment allocation was randomly assigned. H pylori infection was confirmed by positive 13C-urea breath test (13C-UBT). H pylori status was reassessed by UBT at least four and 12 weeks after treatment (negative: d13CO2 below 3.5 per mil). Intention-to-treat (ITT) eradication rates were determined for all patients with confirmed H pylori infection. Per protocol (PP) rate was determined for all patients treated with at least two evaluable follow-up visits., Results: Three hundred five patients were included in the ITT and 222 in the PP analysis. The ITT eradication rates were 66% for RBC-C and 78% for OCA. The PP success rates were 84% for RBC-C and 96% for OCA. The difference for both ITT 12% (95% CI 2 to 22) and PP 12% (95% CI 4 to 19) were statistically significant, P=0.030 and P=0.007, respectively. Treatment was generally well tolerated., Conclusion: The eradication rate for the seven-day dual RBC-C regimen was lower than that for OCA.

Objective: To determine whether a "test for Helicobacter pylori and treat" strategy improves symptoms in patients with uninvestigated dyspepsia in primary care., Design: Randomised placebo controlled trial., Setting: 36 family practices in Canada., Participants: 294 patients positive for H pylori ((13)C- urea breath test) with symptoms of dyspepsia of at least moderate severity in the preceding month., Intervention: PARTICIPANTS were randomised to twice daily treatment for 7 days with omeprazole 20 mg, metronidazole 500 mg, and clarithromycin 250 mg or omeprazole 20 mg, placebo metronidazole, and placebo clarithromycin. Patients were then managed by their family physicians according to their usual care., Main Outcome Measures: Treatment success defined as no symptoms or minimal symptoms of dyspepsia at the end of one year. Societal healthcare costs collected prospectively for a secondary evaluation of actual mean costs., Results: In the intention to treat population (n=294), eradication treatment was significantly more effective than placebo in achieving treatment success (50% v 36%; P=0.02; absolute risk reduction=14%; number needed to treat=7, 95% confidence interval 4 to 63). Eradication treatment cured H pylori infection in 80% of evaluable patients. Treatment success at one year was greater in patients negative for H pylori than in those positive for H pylori (54% v 39%; P=0.02). Eradication treatment reduced mean annual cost by $C53 (-86 to 180) per patient., Conclusions: A "test for H pylori with (13)C-urea breath test and eradicate" strategy shows significant symptomatic benefit at 12 months in the management of primary care patients with uninvestigated dyspepsia.

Objectives: To provide Canadian primary care physicians with an evidence-based clinical management tool, including diagnostic and treatment recommendations, for patients who present with uninvestigated dyspepsia. Recommendations: The management tool has 5 key decision steps addressing the following: (1) evidence that symptoms originate in the upper gastrointestinal tract, (2) presence of alarm features, (3) use of nonsteroidal anti-inflammatory drugs (NSAIDs), (4) dominant reflux symptoms and (5) evidence of Helicobacter pylori infection. All patients over 50 years of age who present with new-onset dyspepsia and patients who present with alarm features should receive prompt investigation, preferably by endoscopy. The management options for patients with uninvestigated dyspepsia who use NSAIDs regularly are: (1) to stop NSAID therapy and assess symptomatic response, (2) to treat with NSAID prophylaxis if NSAID therapy cannot be stopped or (3) to refer for investigation. Gastroesophageal reflux disease can be diagnosed clinically if the patient's dominant symptoms are heartburn or acid regurgitation, or both; these patients should be treated with acid suppressive therapy. The remaining patients should be tested for H. pylori infection, and those with a positive result should be treated with H. pylori-eradication therapy. Those with a negative result should have their symptoms treated with optimal antisecretory therapy or a prokinetic agent. Validation and evidence: Evidence for resolution of the dyspepsia symptoms was the main outcome measure. Supporting evidence for the 5 steps in the management tool and the recommendations for treatment were graded according to the strength of the evidence and were endorsed by consensus of committee members. If no randomized controlled clinical trials were available, the recommendations were based on the best available evidence. Literature review: Evidence was obtained from MEDLINE searches for pertinent articles published from 1966 to October 1999. The searches focused on dyspepsia, diagnosis and treatment. Additional articles were retrieved through a manual search of bibliographies and abstracts from international gastroenterology conferences. Sponsors: Supported by unrestricted educational grants from AstraZeneca Canada Inc., Isotechnika Inc. and Integrated Healthcare Communications Inc. [ABSTRACT FROM AUTHOR]

Objectives: To treat previously untreated adult patients infected with Helicobacter pylori with one of two regimens in an ambulatory community setting to assess the efficacy and safety of these regimens. Methods: Sixty five adult patients with histologically confirmed H. pylori infection were randomly assigned in this open cohort study to 2 wk, low dose, twice daily treatment with omeprazole 20 mg and clarithromycin 250 mg (OC) (n = 31) or OC plus metronidazole 500 mg (OCM) (n = 34). At least 4 wk after treatment, H. pylori status was assessed by histology (four gastric biopsies, two each from antrum and body). Results: Triple therapy with OCM was significantly better than dual therapy with OC in intent-to-treat (82.4 vs 58.1%,p = 0.03) and per protocol analysis (93.3 vs 62.1%, p = 0.004). Although there were frequent side effects (OC 19/31 61.3%; OCM 22/34 64.7% with at least one side effect), these were generally mild, and patients were able to complete nearly all of their medications (OC 97.2%, OCM 96.7% of pills taken). The only patient withdrawn due to medication side effects was in the OC arm. Conclusions: Triple therapy with OCM in a community setting eradicates H. pylori more effectively than dual therapy with OC. OCM is tolerated with high compliance despite frequent minor side effects and appears safe without the development of serious adverse events. [ABSTRACT FROM AUTHOR]

Despite numerous Helicobacter pylori treatment studies, the optimum regimen(s) for its eradication remain unclear. Our objective was to determine systematically which regimen(s) gave the best pooled eradication rates, by using meta-analysis methodology. A total of 27 studies were identified. Pooled eradication rates for single (18.6%), double (48.2%), and triple therapy (82.3%) were statistically highly different (p < 0.0005). Eradication rates with amoxicillin (23.0%) and bismuth compounds (19.6%) were equivalent. Combined treatment with bismuth + metronidazole was better than bismuth + amoxicillin (55.1% vs. 43.7%, p = 0.049). Triple therapy with bismuth + metronidazole + tetracycline gave a statistically higher eradication rate (94.1%) than bismuth + metronidazole + amoxicillin (73.1%, p < 0.0005). Despite increased side effects with multiple antibiotic regimens, patients tolerated these well, without significant drop-out. The combination of bismuth, metronidazole, and tetracycline gives the best eradication rate, but the optimal doses and duration of treatment have yet to be determined. Further studies are necessary to explore factors such as antibiotic resistance and drug compliance as important factors affecting antibiotic efficacy. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Development of guidelines for recently arrived immigrants and refugees to Canada: Delphi consensus on selecting preventable and treatable conditions," by H. Swinkels and colleagues in the 2011 issue.

The article shares the author's remarks concerning the efficacy of first-line therapies for Helicobacter pylori (H pylori). He mentions the meta-analysis of the study by L. Fischbach which affirms the deleterious effect of clarithromycin (CTM) resistance on CTM-containing triple therapies and helps explain their declining efficacy. He added that metronidazole (MTN) resistance seems to be less important than CTM resistance because it can be overcome to some extent.

The author comments on the study which examines the effect of antibiotic resistance status on the efficacy of triple and quadruple therapies for Helicobacter pylori. According to the author, metronidazole (MTN) resistance seems to be less important than clarithromycin (CTM) resistance because it can be overcome to some extent. With the amoxicillin-nitroimidazole-bismuth triple therapy, a larger daily close of nitroimidazole can eradicate resistant strains.